Provider Demographics
NPI:1053658872
Name:MADONNA MANOR INC
Entity Type:Organization
Organization Name:MADONNA MANOR INC
Other - Org Name:MADONNA MANOR HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLAHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-426-6400
Mailing Address - Street 1:2344 AMSTERDAM RD
Mailing Address - Street 2:
Mailing Address - City:VILLA HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3712
Mailing Address - Country:US
Mailing Address - Phone:859-426-6400
Mailing Address - Fax:859-578-7472
Practice Address - Street 1:2344 AMSTERDAM RD
Practice Address - Street 2:
Practice Address - City:VILLA HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3712
Practice Address - Country:US
Practice Address - Phone:859-426-6400
Practice Address - Fax:859-578-7472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251E00000X
KY185241314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1043215296OtherNPI